3 October 2023

Before Assistant Coroner Rachel Redman
Hastings Coroners Court
18 – 25 September 2023

Trevor Monerville was 33 years old when he was found unresponsive following an epileptic seizure in his cell at HMP Lewes on 18 April 2021. 

An inquest has concluded that there was insufficient and unacceptable management of Trevor’s care, inadequate for Trevor’s needs. This is in relation to both HMP Lewes and the privately owned prison healthcare provider, Practice Plus Group (PPG). 

The jury concluded that staff displayed a lack of empathy for the people under their care. Trevor’s death is one of twenty at the prison in the past five years. It is one of a number of epilepsy deaths in prisons nationally, despite repeated recommendations for changes in the care and treatment of epileptic prisoners. 

Trevor was a Black man from Hackney and spent his teens living in Haringey. Naturally gifted with his hands, he was able to assemble any furniture without taking a glimpse at the instructions. He could complete an electrical circuit, fix any car problem and even repair phones and computers. He was a handyman and mechanic by trade. Trevor’s other interests included art, poetry, cooking jerk chicken, baking, tattoos, plumbing and electrics. 

Trevor was diagnosed with epilepsy, and he had received treatment for this since 2016. He experienced frequent seizures, for which he was taking daily medication. 

On 30 November 2020, Trevor was sent to HMP Lewes on recall. He was still having multiple seizures a week at the time. Upon arrival, he told the reception nurse that he had had ten epileptic seizures within the last 48 hours. 

The jury were told that his personal escort record (PER) and comprehensive medical records were available to healthcare staff but were not checked. Subsequently, Trevor’s medical records were not sent to Royal Sussex County Hospital, where he was taken three times as a result of severe seizures in December 2020. 

Thereafter, he was transferred to the prison inpatient unit, where he received care from the prison healthcare provider, PPG. The jury heard there was confusion by staff over whether Trevor suffered from ‘Non-Epileptic Attack Disorder’ or epilepsy. Nevertheless, PPG staff agreed, in evidence to the inquest, that they would not have provided a different standard of care for either condition.    

On 16 January 2021, Trevor was moved back from the inpatient unit to a standard prison wing. From then until the date of his death, Trevor spent the majority of his time alone in a single cell. An expert neurologist told the inquest that sharing a cell would have been the most appropriate option for Trevor. 

The inquest revealed that a cell sharing risk assessment, completed in early January 2021, concluded Trevor was suitable for cell sharing. This was then overridden for unknown reasons by either healthcare or prison staff. The prison officers that gave evidence confirmed there were multiple opportunities for Trevor’s location to be reviewed after he was on the standard wing, but these were not taken despite awareness of risks he faced.

The inquest heard how a suicide and self-harm monitoring process, known as an ACCT, was in place from 25 January - 10 March 2021. It was understood differently by members of staff involved in his care. Some prison officers and healthcare staff believed it was in place to ensure Trevor received increased monitoring for his seizures and not his low mood. However, the ACCT was closed despite Trevor clearly reporting ongoing seizures. 

The expert neurologist considered this decision to have placed Trevor at unnecessary increased risk. After the ACCT was closed, it appears that Trevor received no extra checks or support, despite senior staff accepting they were aware of the risk of nocturnal seizures, and prison and healthcare staff understanding that his seizures could be fatal. 

The officer who, alone, worked on the night shift in the week leading up to Trevor’s death, confirmed that the only night observations on Trevor’s cell were the standard ‘roll checks’, one at 9pm and then one at 5am. CCTV shown to the jury of the 5am check on 18 April 2021 revealed the check lasted only a second and was inadequate for confirming signs of life. 

At 9.47am, a prison officer found Trevor unresponsive in his cell. Emergency services were called and paramedics arrived shortly after. CPR was performed but evidence suggested the response was already too late. Trevor was pronounced dead at 10.59am. The two antiepileptic medications he was prescribed were present in his system at the time he died.

The jury concluded that Trevor died as a result of natural causes in the form of sudden death in epilepsy (‘SUDEP’). In their narrative conclusions they found, unanimously, that: 

• “The communications between all the organisations involved, the monitoring systems, the sharing of medical documentation and the engagement with Trevor’s family were inadequate for Trevor’s individual needs.”
• Even with consideration of staff shortages and the pandemic, “there were and still are not systems in place to have oversight of vulnerable people in Trevor’s position.”
• From their observations of some witnesses, “there is a lack of empathy for the people under their care and tenuous accountability for taking ownership.”

The jury also found there was “no system in place to monitor and document Trevor’s seizures, in the absence of a care plan and a seizure diary”. This contributed to staff not being briefed on Trevor’s vulnerabilities. 

This absence, alongside the lack of systemic observations after the ACCT closed, “contributed to the insufficient and unacceptable management of Trevor’s care.” As did the ongoing issues in prisons and healthcare, with the various IT systems not being integrated. 

The coroner has scheduled a further hearing on 26 October to consider ongoing issues arising from the evidence of the inquest, and to potentially make recommendations for change in a report to prevent future deaths.

Trevor’s mother, Sonia Oke, said: “After many years of sadness, numbness and despair that the system has put my son Trevor, myself and my family through, today I say that nothing has changed. The system had the responsibility for my son’s life, and they handled his life with carelessness, non-existent duty of care and severe negligence. 

My son’s final days on this earth were of suffering through the hands of the law. The blood is indeed on the members of staff that have taken part in this case amongst the entire prison system hands. My son Trevor has lost his entire life, and there is nothing that can change this. Reiterating and hearing the mistreatment that he went through only furthers the hole in my heart. 

Hearing the countless failed attempts of trying to communicate with the prison as I worried and remained anxious about my son’s treatment every second of every day only weakens me to my knees. Me and my children will remain heartbroken. Years and months we had to wait and wait and wait for this system to show humanity to my son even when he had passed. 

What a failing beyond words the system has been towards my son Trevor. Words cannot describe the animalistic service and treatment that we have received from this system. A system with no plan of improvement and many hundreds of thousands of people are going through this exact treatment as we speak. 

Justice will never truly be made because a life cannot be resurrected. Trevor showered me with his love throughout the past 6 days which has given me strength to stand amongst a court today. But implanting an action of change within the prison service is the only way forward.”

Trevor’s siblings said: "When the forewoman was reading the jury’s conclusion, it got to a point where we heard Trevor’s voice, and remembered him saying on the phone “they don’t care, they don’t care”. He was right the whole time. If we don’t put a stop to this, it will keep on happening. Why do we have to wait for someone to pass away tragically before changes are made in the system?"

Paul Ham and Constance Collard of Birnberg Peirce, representing the family, said: “Despite multiple warnings from Trevor, his mother and other family members, healthcare and prison officers failed to take the risk of his seizures, especially nocturnal seizures, seriously. 

The prison failed to consider how sharing a cell could have kept Trevor safer. There was a woeful lack of understanding around the monitoring or recording of seizures. The jury rightly noted the inadequate communication, lack of empathy and not taking ownership of Trevor’s care by staff.”

Jodie Anderson, Senior Caseworker at INQUEST, said: “Trevor entered prison with a very treatable condition, and within five months had died. His family deprived of a brother, son, friend. The jury has recognised the catalogue of failings.

Trevor was put into a single cell despite guidance and reports advising against this, and failures to properly monitor his condition ultimately cost him his life. The prison service’s abject refusal to learn from and prevent deaths demonstrates the urgent need for a National Oversight Mechanism, which would ensure that recommendations are not simply dismissed or ignored.”

ENDS 

NOTES TO EDITORS

For further information, please contact Lucy McKay on [email protected] or 020 7263 1111

The family are represented by INQUEST Lawyers Group members Paul Ham and Constance Collard of Birnberg Peirce and Allison Munroe KC of Garden Court Chambers. They are supported by INQUEST Senior Caseworker Jodie Anderson.

Other Interested Persons represented at the inquest are HMP Lewes, Practice Plus Group (PPG), University Hospitals Sussex NHS Foundation Trust. 

ACCT is an acronym for: ‘Assessment, Care in Custody and Teamwork’: a plan of support for someone in prison who is at risk of self-harm or suicide.

The Trevor Monerville Campaign run by the family can be found at @TrevCampaign on Twitter and @Trevor.monerville_campaign on Instagram. They seek to bring about change by way of a national policy that can address the deficit in care for prisoners who experience seizures. 

INQUEST’s No More Deaths campaign is calling for a National Oversight Mechanism which would ensure potentially life-saving recommendations are no longer forgotten, dismissed or simply not implemented. INQUEST believes this could have prevented deaths like Trevor’s, after other similar deaths led to recommendations around the treatment of prisoners with epilepsy or seizures. 

Other relevant cases:

• Amarjit Singh, aged 41, was found dead in his cell at HMP Pentonville on the morning of 21 November 2021. In the middle of the night his cellmate had rung the emergency cell bell and told the prison officer who came to the door that Mr Singh had suffered a fit. However, the prison officer did not then seek medical attention for Mr Singh and the cell door remained locked shut for the rest of the night. The prison officer who did not seek medical attention for Mr Singh was investigated and was found guilty of gross misconduct. Prevention of Future Deaths report.
• David Andrew Llewellyn O’Garro died from a sudden death in epilepsy on 2 June 2014 in a single cell in HMP Pentonville. Following the inquest, the coroner issued a Prevention of Future Deaths report highlighting how people with epilepsy should not occupy single cells as no one can raise the alarm when they are having a seizure. Prevention of Future Deaths report.
• Daniel Adewole, 16, was found unresponsive in his cell at HMYOI Cookham Wood following an epileptic fit in 2015. Prison officers failed to enter his cell to check for his safety for 38 minutes after receiving no response from Daniel’s door and went for a cigarette instead. The coroner concluded that prison officers should have entered his cell much sooner. Media release.

An audit of epilepsy healthcare provision in UK prisons found that adults in prison are more likely to have or develop epilepsy.